Pulmonology
Physician discussions on respiratory conditions, critical care, interstitial lung disease, and pulmonary procedures.
Recent Discussions
How do you mitigate the risk of inadverdent under or over diagnosis of COPD in certain populations with transition to race-neutral spirometry reference equations?
Hi - I use the GOLD guidelines of fixed (rather than % predicted) FEV1/FVC ratio of < 0.7 to define obstruction for COPD. Most of the major studies in forming COPD treatment have used the fixed ratio. There is a risk of overdiagnosis in an older population with the fixed ratio, but in an older indiv...
Do you choose an antibiotic with CSF penetration, such as nafcillin over cefazolin, in the setting of MSSA endocarditis with septic emboli to the brain (assuming no concomitant meningitis or brain abscess)?
The prevailing theory that cefazolin has poor CNS penetration is really based on 3-4 studies performed in the 1980s (Nolan & Ulmer, PMID 7365282) where they were extrapolating data from studies looking at cephalothin concentration in CSF. Another study looking specifically at cefazolin concentration...
What is the role of mechanical circulatory support in mixed cardiogenic vasodilatory shock?
To structure management for any individual patient with "mixed" shock, it is prerequisite to define the nature, sequence and contributors to the admixture of circulatory derangements. Temporary mechanical circulatory support (tMCS) provides hemodynamic value for patients with a critical insufficienc...
What factors influence your decision to initiate antifungal treatment in asymptomatic lung transplant recipients colonized with Aspergillus?
My main driver for using Aspergillus treatment/prophylaxis for asymptomatic colonized patients is their level of immunosuppression; if they have received augmentation for rejection or because of a treatment for cancer, I would strongly consider treatment; another reason would be if they are listed f...
Do you utilize the bronchiectasis severity index (BSI) in your approach to managing non-CF bronchiectasis?
I calculate it for academic reasons in my bronchiectasis clinic. It perhaps affects the frequency of visits in the clinic. Otherwise, not much practical application. I respond to daily cough and secretion management with stepping up airway clearance, and to frequency bronchiectasis exacerbations wit...
Do you have any tips for effectively performing EBUS with biopsy at the 4L lymph node station?
Are you using LMA or ETT or performing under moderate sedation. This may impact orienting your scope and subtle movements/maneuvering for 4L stations. A few things that will help is — relax your arm with elbows to your pelvis and drop the forearm leftwards (create a slant so as to have full rotatio...
How do you rule out empyema in a small pleural effusion that is not amenable to thoracentesis?
Ultrasonographic findings indicate empyema, such as complex septated or non-septated/echogenic effusions Wang et al., PMID 35984158. However, if the effusion is too small, it may be difficult to characterize, limiting the diagnosis. Moreover, when the effusion is so small, the likelihood of empyema ...
What factors prompt you to consider revision vs removal of endobronchial valves in patients who do not develop atelectasis after BLVR?
Usually, when patients don’t have symptomatic improvement, especially when they feel worse. I would use PFT as a reference, but not the only criteria. Discussing with the patient is also important.
Do you have any strategies to increase yield while doing a BAL?
The key is not to rush. Obtain good topical anesthesia around the bronchial segment selected for BAL to minimize coughing during the procedure and maintain a good seal. Administer lavage fluid slowly and gently, advancing the scope during infusion to "tighten" the seal. Have the therapist/nurse slow...
Do you consider early belatacept based immunosuppression in lung transplant recipients?
Belatacept is not always easy to obtain and utilize; in addition, it is not as effective as usual triple immunosuppression (Tac, MMF, Pred or other equivalents) in order to replace any of the meds; I usually do not consider as an additional medication. In exceptional circumstances, where there many ...